FORM 3

CHILD NUTRITIONAL STATUS & SELF-HELP FORM

Instructions to Parents/Guardians: The following information is

required for your child attending the CDC for record purposes. Please
complete this form by providing information called for. For some of the
items, the Municipal/Rural/Barangay Health Unit Officer (M/R/BHUO), or
Barangay Nutrition Scholars (BNS) is required to provide the
information. This is to be given to the Child Development Teacher as of
the child’s portfolio.

BASIC INFORMATION

Child’s Name: _______________________________________________________

Last First Middle

Birth Date: __________________________ Sex: M F

Address: ____________________________________________________________

___________________________________________________________________

Parent/Guardian Name(s)______________________ Relationship:

_____________
Phone Number(s): Work: ____________________ Home: ____________________
Mobile Number(s): ________________, _________________, _________________

NUTRITION INFORMATION:

Results Date Taken

Test/Measurement
1st 2nd 1st 2nd

Height

Child Nutritional Status Form Page 1

 Weight

Nutritional Status

Name M/R/BHU Phone No.: Signature:

Officer/BNS:

Date: ____________________

FEEDING/EATING:

1. Does your child have any food allergies we need to be aware of?
__________
2. What food do you usually give to your child?
__________________________
3. What is your child eating habbit? (i.e. bottles, finger foods, fruits,
cereal, etc.) _______________________________________________________
4. Is your child using a bottle? ________ If so, how often will s/he take
for a day? ________
5. What time does your child usually have: Breakfast ______ Lunch
______ Dinner _______
6. Is your child used to have a meal time snacks? Yes No

7. What food is normally eaten by your child?

Vegetable Rice Pork Cereals Noodles Fruit

Juice

Chicken Soup Milk Meat Bread Fish

Fruits

8. Does this child need any help in feeding himself/herself? Yes

No

NAPPING/SLEEPING:

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 9. Does your child nap? Yes No

10. Does your child have a good sleep through the night? Yes
No

11. What time does your child get up in the morning? _______________

12. Does this child have any special nap or bedtime routine? Yes
No

BATHING/WASH-UP:
13. How do you bath/wash-up your child? _____________ How often?
________
14. Do you use baby soap? ____ Any soap? _____ Baby Shampoo?
_________
15. Does your child have allergies in soap, shampoo, etc.? Please
specify; _____
16. Do you put baby oil after bath/wash-up? ______________ Powder?
_______

TOILETING:
17. Is your child toilet trained? Yes No At what age? ____
18. Does your child doing any toileting? _______________ How often?
19. Does your child have a special word for urinating? ___ Bowel
Movement: ___
20. Is your child using diaper? ___________ Cloth Disposable
21. How would you know if your child needs new diaper (S/He brings
diaper to you, cries, you have to check)?
____________________________________
22. How often do you change his/her diaper/baby clothes?
__________________

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 I ATTEST THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE
AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I
UNDERSTAND IT IS FOR CONFIDENTIAL USE IN MEETING MY CHILD’S
HEALTH NEEDS IN NCDC.

Accomplished by : ______________________________ __________________

Signature over printed name of parent/guardian
Date

Reviewed by: ____________________________

__________________
Signature over printed name of CD T
Date

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